Urinary tract obstruction (UTO), a potentially reversible cause of renal failure (RF), should be considered in all cases of acute or abrupt worsening of chronic RF. Consequences depend on duration and severity and whether the obstruction is unilateral or bilateral. UTO may occur at any level from collecting tubule to urethra. It is preponderant in women (pelvic tumors), elderly men (prostatic disease), diabetic pts (papillary necrosis), pts with neurologic diseases (spinal cord injury or multiple sclerosis, with neurogenic bladder), and individuals with retroperitoneal lymphadenopathy or fibrosis, vesicoureteral reflux, nephrolithiasis, or other causes of functional urinary retention (e.g., anticholinergic drugs).
Pain can occur in some settings (obstruction due to stones) but is not common. In men, there is frequently a history of lower urinary tract symptoms, e.g., hesitancy, urgency, or frequent nocturia. Physical examination may reveal an enlarged bladder by percussion over the lower abdominal wall; bedside ultrasound assessment (“bladder scan”) can be helpful to assess the postvoid bladder volume. Other findings depend on the clinical scenario. Prostatic hypertrophy can be determined by digital rectal examination. A bimanual examination in women may show a pelvic or rectal mass. The workup of pts with RF suspected of having UTO is shown in Fig. 149-1. Laboratory studies may show marked elevations of blood urea nitrogen and creatinine; if the obstruction has been of sufficient duration, there may be evidence of tubulointerstitial disease (e.g., hyperkalemia, non-anion-gap metabolic acidosis, mild hypernatremia). Urinalysis is most often benign or with a small number of cells; heavy proteinuria is rare. An obstructing stone may be visualized on abdominal radiography or helical noncontrast CT with 5-mm cuts.
Diagnostic approach for urinary tract obstruction in unexplained renal failure. Circles represent diagnostic procedures, and squares indicate clinical decisions based on available data.
Ultrasonography can be used to assess the degree of hydronephrosis and the integrity of the renal parenchyma; CT or IV urography may be required to localize the level of obstruction. Calyceal dilation is commonly seen; it may be absent with hyperacute obstruction, upper tract encasement by tumor or retroperitoneal fibrosis, or indwelling staghorn calculi. A nuclear renal scan to assess excretion of the radioisotope technetium Tc-99m mertiatide (Tc-99m MAG3), before and after administration of a loop diuretic may be helpful for functional assessment of obstruction; it can also identify a difference in function between the two kidneys. Imaging in retroperitoneal fibrosis with associated periaortitis classically reveals a periaortic, confluent mass encasing the anterior and lateral sides of the aorta. Kidney size may indicate the duration of obstruction. It should be noted that unilateral obstruction may be prolonged and severe (ultimately leading to loss of renal function in the obstructed kidney), with no hint of abnormality on physical examination and laboratory survey.